HEALTHCHOICE MANUAL FOR PROVIDERS OF SELF-REFERRAL …

HEALTHCHOICE MANUAL

FOR

PROVIDERS

OF

SELF-REFERRAL

AND

EMERGENCY SERVICES

August 2010

2

TABLE OF CONTENTS

INTRODUCTION Pages 3-8

CHILD IN STATE-SUPERVISED CARE-INITIAL MEDICAL EXAM Pages 9

EMERGENCY SERVICES Pages 10-11

FAMILY PLANNING SERVICES Pages 12-13

HIV/AIDS ANNUAL DIAGNOSTIC AND EVALUATION SERVICE

VISIT Page 14

NEWBORN’S INITIAL MEDICAL EXAMINATION IN A HOSPITAL Pages 15-16

PREGNANCY-RELATED SERVICES INITIATED PRIOR TO MCO

ENROLLMENT Pages 17-19

RENAL DIALYSIS SERVICES PROVIDED IN A MEDICARE-CERTIFIED

FACILITY Pages 20-21

SCHOOL-BASED HEALTH CENTER SERVICES Pages 22-25

SUBSTANCE ABUSE TREATMENT 6-37

SUBSTANCE ABUSE FORMS Pages 38-58

MCO RESOURCE LISTS Pages 59-62

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INTRODUCTION PURPOSE

The purpose of this manual is to assist health care providers to identify circumstances

under which HealthChoice members may obtain “self-referral” services from an out-of-plan

provider and to provide guidance on submitting claims to the member’s Managed Care

Organization.

HealthChoice is the name of Maryland’s Medicaid Managed Care Program that was

implemented in June of 1997. Under this program, the majority of Medical Assistance recipients

receive their benefits through a managed care organization (MCO). There are currently seven

MCOs serving Medicaid recipients in Maryland:

*AMERIGROUP, Maryland Inc. *Maryland Physicians Care

*Diamond Plan/Coventry *Priority Partners

*Helix Family Choice *UnitedHealthcare

*Jai Medical System

DEFINITION

Self-referral services as defined in the HealthChoice regulations, Maryland Medicaid Managed

Care Program, COMAR 10.09.62, are “health care services for which under specified

circumstances, the MCO is required to pay, without any requirement of referral by the primary

care provider (PCP) or MCO when the enrollee accesses the service through a provider other

than the enrollee’s PCP.”

While MCO members are required to use in-network providers for most medical services,

under certain circumstances, MCOs are responsible for some out-of-network care received by

their members. These circumstances and payment requirements are defined in COMAR

10.09.67.28 under Benefits-Self-Referral Services and COMAR 10.09.65.20 under MCO

Payment for Self-Referred Emergency and Physician Services.

The circumstances under which MCOs must pay for out-of-network care can be classified

into three types:

• Self-referral provisions for all MCO members;

• Continuity of care for new MCO members; and

• Emergency care provisions.

A “classic” example of a self-referral provision is the ability of all MCO

members to access family planning services from the provider of their choice.

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RESPONSIBILITIES OF MEMBERS AND PROVIDERS

When seeking care without an MCO/PCP referral or authorization for a “self-referral”

service, HealthChoice members should present their MCO card to the provider. The MCO is

required to have the member’s Medical Assistance number on the MCO card. Self-referral

providers should call the Eligibility Verification System (EVS) at 1-866-710-1447 prior to

rendering care. To use this system you must have a Medicaid provider number.

ELIGIBILITY VERIFICATION SYSTEM

The Maryland Medicaid Eligibility Verification System (EVS) is a telephone inquiry

system that enables health-care providers to quickly and efficiently verify a Medicaid

recipient’s current eligibility status.

A Medical Assistance card alone does not guarantee that a recipient is currently

eligible for Medicaid benefits. You can call EVS to quickly verify a recipient’s

eligibility status. To ensure recipient eligibility for a specific date of service, you

must use EVS prior to rendering service.

EVS is fast and easy to use, and is available 24 hours a day, 7 days a week. EVS

requires only seconds to verify eligibility and during each call you can verify as

many recipients as you like.

EVS is an invaluable tool to Medicaid providers for ensuring accurate and timely

eligibility information for claim submissions.

Providers may download the EVS/IVR user brochure, which contains additional details

about the new system, by accessing the Department’s website at

www.dhmh.state.md.us/medcareprog.

For providers enrolled in eMedicaid, WebEVS, a web-based eligibility application, is

available at www.emdhealthchoice.org. Providers must be enrolled in eMedicaid in

order to access WebEVS. To enroll and access WebEVS go to URL above, select

‘Services for Medical Care Providers’, and follow the login instructions. If you need

information, please visit the website or for provider application support call 410-767-

5340.

If you have questions concerning the new system, please contact the Provider Relations

Division at 410-767-5503 or 1-800-445-1159.

WHAT YOU NEED

1. A touchtone phone

2. The EVS access telephone number

http://www.dhmh.state.md.us/medcareprog

http://www.emdhealthchoice.org/

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3. Your Medicaid provider number

4. The recipient Medicaid number and name code (or social security number

and name code)

HELPFUL TIPS

You must press the pound key twice (##) after entering data requested in each

prompt.

If you make a mistake, press the asterisk (*) key once. EVS disregards the

incorrect information and repeats the prompt.

If you do not enter data within 20 seconds after a prompt, EVS re-prompts you.

If you fail to enter data after the second prompt, EVS will disconnect the call.

If you need to hear a verification a second time, press “1” and the information

will be repeated. Press “2” in order to enter the next recipient’s information.

To end the call you must promptly press the pound key twice (##). Otherwise,

your phone line will remain in service for 20 seconds allowing no other incoming

calls.

EVS provides current information up to the previous business day. Please listen

closely to the entire EVS message before ending the call so that you don’t

miss important eligibility information.

The EVS message will give you the name and phone number of the recipient’s

managed care organization (MCO), if he or she is enrolled in “HealthChoice”. If

the recipient is a member of an MCO, you can press “3” and the call will be

transferred directly to the MCO’s call center to verify Primary Care Physician

(PCP) assignment.

For a recipient in a facility, provider will be given the name and phone number of

the facility.

The EVS message for recipients that have Medicaid and are “fee-for-service”

(not enrolled in HealthChoice) is “eligible, federal, MCHP”.

The EVS message for women in the Family Planning Program is eligible,

federal, family planning only”.

If you have questions about the different types of eligibility, call the MCHP and

Family Planning Program at: 800-456-8900.

If you need further assistance with EVS, call Provider Relations Monday-Friday

between 8:00a.m. and 5:00p.m. at 410-767-5503 or 800-445-1159.

HOW TO USE EVS

Call the EVS access telephone number by dialing:

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1-866-710-1447

Enter your 9 digit provider number and press the pound key twice (##)

Example: 012345678#

For current eligibility enter the 11 digit recipient number and the 2-digit name

code (the first two letters of the last name converted into numeric touchtone

numbers) and press the pound key twice (##).

Example: For recipient Mary Stern, you would enter:

11223344556 (recipient ID number) and 78## (7 is for “S” in Stern and 8 is for

“T” in Stern)

NOTE: Since the characters Q and Z are not available on all touchtone phones,

enter the digit 7 for the letter Q and digit 9 for the letter Z.

EVS will respond with current eligibility information or an error message if

incorrect information has been entered.

For past eligibility you can search a recipient’s past eligibility status for up to

one year. To do a search of past eligibility, enter a date of up to one year using

the format MMDDYYYY

Example: For recipient Mary Stern, where the date of service was January 1,

1995, you would enter:

11223344556 (recipient ID#) AND 78 (last name code) and 01011995# (service

date)

Past eligibility can be obtained by entering the recipient’s social security number,

name code and date of service.

EVS will respond with eligibility information for the date of service requested or

an error message if incorrect information was entered.

NOTE: Should you enter the date incorrectly, EVS re-prompts you to re-enter

only the date up to 3 consecutive times. However, at the prompt, you can return

to the “ENTER RECIPIENT NUMBER AND NAME CODE” prompt by

entering “9” and pressing the pound key twice (##).

If the recipient’s number is not available: At the recipient number prompt,

press “O” and press the pound key twice (##). In this case, EVS prompts you

with the following: “ENTER SOCIAL SECURITY NUMBER AND NAME

CODE”.

Example: 111223334 (SSN) and 78## (last name code)

Note: Social Security Numbers are not on file for all recipients. If the Social

Security Number is not on file, eligibility cannot be verified until the Medical

Assistance number is obtained. If you have entered a valid SSN and the recipient

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is currently eligible for Medical Assistance, EVS will provide you with a valid

recipient number, which you should record, and recipient’s current eligibility

status.

To continue checking eligibility for additional recipients, enter another recipient

number or immediately press the pound key twice (##) to end the call.

It is important to end the call by pressing the pound key twice (##) to free both

your phone line and the EVS line for the next caller.

• If EVS indicates that the recipient is eligible for Medical Assistance on the date of

service, but is not enrolled in an MCO, the provider must bill the Medical Assistance

Program for the service rendered. In this case, self-referral provisions in this manual

do not apply and the provider must follow all established Medicaid fee-for-service

policies.

• If EVS says the recipient is enrolled in an MCO on the date of service, and a self-

referral service was rendered, as described in this manual, the provider must bill the

MCO for the self-referral service.

• For additional information about the EVS call the Medical Assistance Provider

Relations Unit at (410) 767-5503 or 800-445-1159.

When the recipient is enrolled in an MCO the provider of a self-referral service should

establish communication with the primary care provider (PCP). Look at recipient’s MCO card,

ask the member for the name of their PCP or, if necessary, call the MCO to determine the name

of the PCP (as this information is not on EVS).

Providers of “self-referral” services need to be familiar with the scope and frequency of

services allowed under the self-referral provisions prior to rendering care. When the provider

determines that services beyond the scope of the self-referral provisions are medically necessary,

preauthorization should be sought from the MCO. As required by COMAR 10.09.66.07 B(4),

the MCO must approve the preauthorization in a timely manner so as not to adversely affect the

health of the member, but no later than 72 hours after the initial request. The MCO must notify

the provider in writing whenever the provider’s request for preauthorization for services is

denied.

QUALITY ASSURANCE REQUIREMENTS

Providers who render self-referral services must cooperate with the Department’s quality

assurance reviews. This means that if an MCO informs the provider that a HealthChoice

member’s medical record has been selected for quality assurance review, the provider must

provide the record to the MCO.

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PHARMACY AND LABORATORY SERVICES

MCOs require enrollees to utilize in network pharmacy and laboratory services ordered by

out-of-plan providers. The HealthChoice regulations provide for an exception to this

requirement when:

• Medically necessary pharmacy or laboratory services are provided in connection

with a self-referral service; and

• The pharmacy or laboratory services are provided on-site by the out-of-plan

provider at the same location where the self-referral service was delivered.

The MCO must pay the Medicaid rate for pharmacy or laboratory services provided on-

site by an out-of-plan provider at the same location where the self-referral service was delivered.

When a self-referral provider is unable to render or chooses not to render the pharmacy or

laboratory service at the same location where the self-referral service was delivered, the provider

must refer HealthChoice members to in-network providers of pharmacy and laboratory services.

BILLING INSTRUCTIONS AND LIMITATIONS

Providers who have agreed to provide a self-referral service to a HealthChoice member

may not balance bill the member or charge for any service that is covered by the Medical

Assistance Program. Providers must use the billing codes in this manual, where specified, for

submitting claims for self-referral services to the MCO. Where no specific codes have been

designated, requests for payments should be submitted using the procedure codes and invoice

forms specified in the MCO provider manual. The member’s MCO card will have information

on where to call for claims information or where to submit claims. If additional billing

information is needed, call the MCO provider relations unit. Refer to the MCO Resource List on

pages 59-62

Providers rendering self-referral services must submit claims to the MCO within six (6)

months of the date of service.

MCO REIMBURSEMENT

An MCO, or in some instances its subcontracted medical management group, must

reimburse out-of-plan providers for self-referred services to its enrollees at the established

Medicaid rate, unless specifically noted otherwise in this manual or COMAR regulations.

MCOs must reimburse out-of-plan providers for undisputed self-referral claims within thirty (30)

days of receipt.

The MCO is also responsible for reimbursing out-of-plan providers at the Medicaid rate

for medically necessary pharmacy and laboratory services when the pharmacy or laboratory

service is provided on site by the out-of-plan provider at the same location where the self-referral

service was delivered. The Specialty Mental Health System (Value Options) is responsible for

assisting a state supervised child to access specialty mental health services and payment of the

mental health screen and a medical examination necessary for an inpatient psychiatric admission.

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CHILD IN STATE-SUPERVISED CARE-INITIAL MEDICAL

EXAM

Type of Provision: Self-Referral A child in State supervised care is a child in the care and custody of a State agency

pursuant to a court order or voluntary placement agreement, including, but not limited to

HealthChoice-eligible children that are:

• Under the supervision of the Department of Juvenile Services,

• In kinship or foster care under the Department of Human Resources, or

• In residential treatment centers or psychiatric hospitals for the first 30 days after

admission.

Prior to rendering care to a child in State supervised care a provider must receive EPSDT

certification from the Department of Health and Mental Hygiene.

The MCO is required to permit the self-referral of a child in State-supervised care for an

initial examination and is obligated to pay for all portions of the examination except for the

mental health screen. Eligible providers should bill the child’s MCO utilizing the age

appropriate preventative CPT code (see code list below) in conjunction with the modifier -32

(Mandated Services). Eligible providers will be reimbursed by MCOs at the current Medicaid

Fee for Service rate.

FOR CURRENT FEE SCHEDULE, SEE THE MEDICAID PROVIDER FEE MANUAL,

ON LINE AT:

http://www.dhmh.state.md.us/mma/providerinfo/

CPT Code Description

Initial Comprehensive Preventive Medicine (New Patient)

99381 Infant (age under 1 year)

99382 Early Childhood (age 1 through 4 years)

99383 Late Childhood (age 5 through 11 years)

99384 Adolescent 9 (age 12 through 17 years)

or

Periodic Comprehensive Preventive Services (Established Patient)

99391 Infant (age under 1 year)

99392 Early Childhood (age 1 through 4 years)

99393 Late Childhood (age 5 through 11 years)

99394 Adolescent (age 12 through 17 years)

Contact the staff specialist for Children’s Services for additional information at (410)

767-1903.


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EMERGENCY SERVICES

Type of Provision: Emergency Care

The HealthChoice regulations require MCOs to reimburse a hospital emergency facility

and provider, which is not required to obtain authorization or approval for payment from an

MCO in order to obtain reimbursement under this regulation, for:

(1) Emergency services that are provided in a hospital emergency facility after the

sudden onset of a medical condition that manifests itself by symptoms of sufficient

severity, including severe pain, that the absence of immediate medical attention

could reasonably be expected by a prudent lay person, who possesses an average

knowledge of health and medicine, to result in:

• Placing the patient’s or with respect to a pregnant woman, the health of

the woman or her unborn child, in serious jeopardy;

• Serious impairment to bodily functions; or

• Serious dysfunction of any bodily organ or part.

(2) The medical screening services that meet the requirements of the Federal

Emergency Medical Treatment and Active Labor Act;

(3) Medically necessary services which the MCO authorized, referred, or instructed the

enrollee to be treated at the emergency facility or medically necessary services that

relate to the condition which presented when the enrollee was allowed to use the

emergency room facility; and

(4) Medically necessary services that relate to the condition presented and that are

provided by the provider in an emergency facility to the enrollee, if the MCO fails

to provide 24-hour access to a physician.

Hospital emergency room staff should not call MCOs for authorization to provide

services that meet the above criteria. Instead, they should deliver the services then bill the

enrollee’s MCO. The MCOs have the right to ask the hospitals to provide information to

document that emergency services met one of the above criteria. MCOs do not have the right to

refuse payment for a service that meets any of the above criteria on the grounds that a hospital

did not request preauthorization. In addition, MCOs may not deny payment for medically

necessary diagnostic services that the hospital ordered in their effort to determine if the

presenting condition is emergent.

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The claim must be submitted to the MCO within six (6) months of the date of service.

The MCO shall reimburse the emergency facility and the provider at the Medicaid rate. The

hospital should bill the MCO by submitting a UB 04 claim form using revenue code 450 and any

other appropriate revenue code. Providers should bill the MCO by submitting a CMS 1500 claim

form.

The following CPT codes must be used by providers to bill for these services:

FOR CURRENT FEE SCHEDULE, SEE THE MEDICAID PROVIDER FEE

MANUAL, ON LINE AT:


CPT Code Description/Presenting Problem

99281 Emergency department visit, minor

99282 Emergency department visit, low-moderate

99283 Emergency department visit, moderate severity

99284 Emergency department visit high severity

99285 Emergency department visit, immediate threat

99288 Physician directed EMS

For additional information regarding the facility charges, contact the Health Services

Cost Review Commission at (410) 764-2605 for specific hospital discounts relating to graduate

medical education.


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FAMILY PLANNING SERVICES

Type of Provision: Self-Referral

Family Planning Services are services which provide individuals with the information

and means to prevent an unwanted pregnancy and maintain reproductive health, including

medically necessary office visits and the prescription of contraceptive devices. Federal law

permits Medicaid recipients to receive family planning services from any qualified provider.

HealthChoice members may self-refer for family planning services without prior authorization or

approval from their PCP with the exception of sterilization procedures.

The scope of services covered under this provision is limited to those services required

for contraceptive management. The diagnosis code (V25) must be indicated on the claim form in

order for the MCO to recognize that the Evaluation and Management code is related to a Family

Planning Service. The following CPT codes must be used to bill MCOs for these services:


99201 Office visit, new patient, minimal

99202 Office visit, new patient, moderate

99203 Office visit, new patient, extended

99204 Office visit, new patient, comprehensive

99205 Office visit, new patient, complicated

99211 Office visit, established patient, minimal

99212 Office visit, established patient, moderate

99213 Office visit, established patient, extended

99214 Office visit, established patient, comprehensive

99215 Office visit, established patient, complicated

99384 Child office visit, new patient, preventative (age 12-17)

99385

Adult office visit, new patient, preventative (age 18-39)

99386

Adult office visit, new patient, preventative (age 40-64)

99394

Child office visit, established patient (age 12-17)

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99395 Adult office visit, established patient

(age 18-39)

99396 Adult office visit, established patient (age 40-64)

57170 Diaphragm fitting with instructions

58300 Insert Intrauterine Device

58301 Remove Intrauterine Device

58565 Essure (procedure)

11976 Remove contraceptive capsules

11981 Insert Drug Implant

11982 Remove Drug Implant

11983 Remove/insert Drug Implant

J1055 Depo-Provera-FP

J7300 IUD Kit

J7302 Mirena System

J7303 Contraceptive Vaginal Ring

J7304 Contraceptive Hormone Patch

J7307 Implanon

A4261 Cervical Cap

A4266 Diaphragm

99070 Other Contraceptive Product


ON LINE AT:


Special contraceptive supplies not listed above should be billed under procedure code 99070.

Note: A copy of the invoice for the contraceptive product must be attached to the claim when

billing under procedure codes 99070, A4261, A4266, J7302 J7303, and J7304.

MCOs must pay providers for pharmacy items and laboratory services when the service is

provided on-site in connection with a self-referral service. For example, MCOs must reimburse

medical providers directly for the administration of Depo-Provera from a stock supply of the

drug. This eliminates unnecessary barriers to care which are created when members are asked to

go to an outside pharmacy to get a prescription for Depo-Provera filled and then are required to

return to the provider’s office for the injection. Contact the staff specialist for Family Planning

services for additional information at (410) 767-6750.


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HIV/AIDS ANNUAL DIAGNOSTIC AND EVALUATION

SERVICE

Type of Provision: Self-Referral HealthChoice members diagnosed with human immunodeficiency virus or acquired

immune deficiency syndrome (HIV/AIDS) are entitled to one self-referral annual diagnostic and

evaluation service (DES) assessment provided by an approved HIV DES provider.

MCOs are responsible for reimbursing DES providers for an annual HIV assessment

provided to MCO members with HIV/AIDS. The following conditions must be met:

• A comprehensive medical and psychosocial assessment or reassessment must be

provided.

• A written, individualized plan of care by a multi-disciplinary team convened by an

approved HIV DES provider must be developed or revised and completed on a form

approved by the Program.

• A copy of the completed pediatric or adult plan of care, which has been signed by all

members of the multi-disciplinary team and the recipient or legally authorized

representative, must be sent to the recipient’s primary medical provider (PCP) and

MCO.

• The procedure code to be used for billing the annual diagnostic and evaluation service

(DES) is: S0315. The DES provider should bill the MCO on the invoice form

specified by the MCO within 6 months.

• The MCO must reimburse the DES provider the current Medicaid rate.

• All children ages 0-20, including infants, with a diagnosis of inconclusive HIV result

(042.x all; V08; 795.71, 0-12) are eligible for enrollment in the Rare and Expensive

Case Management Program (REM). A recipient who becomes eligible for REM

while enrolled in an MCO may chose to remain enrolled in the MCO.

• Most children diagnosed with HIV/AIDS are enrolled in REM except for those who

elect to remain in the MCO. All adult recipients with HIV/AIDS will remain enrolled

or be enrolled in MCOS.

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NEWBORNS INITIAL MEDICAL EXAMINATION IN A

HOSPITAL

Type of Provision: Continuity of Care

Newborns of HealthChoice members must have access to an initial newborn examination

in the hospital. Babies born to HealthChoice members will be enrolled in the mother’s MCO

effective on the date of birth. In order to assure continuity of care the following actions must be

taken:

• Prenatal care providers should instruct pregnant women to call their MCO/PCP. She

should inform the MCO of her pregnancy and request that the MCO link her with a

pediatric provider prior to delivery;

• OB, pediatric and hospital providers should encourage the woman to notify her

MCO as soon as possible after delivery;

• Hospitals should fax a completed Hospital Report of Newborn form, DHMH 1184

to the Department at: 410-333-7012 within 24 hours.

• The MCO is responsible for arranging subsequent newborn care, including routine

and specialty care;

• The MCO is responsible for arranging for specialty care and the emergency transfer

of newborns to tertiary care centers.

The MCO must reimburse out-of-plan providers for an initial medical examination

of a newborn when:

(1) The examination is performed in a hospital by an on call physician; and

(2) The MCO failed to provide for the service before the newborn’s discharge from the

hospital.

When an out-of-plan provider bills the MCO for newborn care, history and examination

CPT 99460 should be used. The MCO should pay the on-call provider, the in-network rate but

no less than the Medicaid rate for this service. Contact the nurse consultant in the Division of

Outreach and Care Coordination at (410) 767-6750 for additional information.

The newborn coordinator at each MCO will assist providers with newborn related issues

or problems.

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MCO Newborn Coordinators

MCO Newborn

Coordinator

Phone Number

Newborn

Coordinator

Fax Number

AMERIGROUP Maryland Inc.

7550 Teague Road,

Suite 500

Hanover, MD 21076

(410) 859-5800

1-800-981-4085

877-855-7559

Diamond Plan

Coventry Health Care of Delaware, Inc.

6310 Hillside Court

Suite 100

Columbia, MD 21244

1-866-212-5305

410-910-7118

410-910-6980

Jai Medical Systems, Inc.

5010 York Road

Baltimore, MD 21212

(410) 433-2200

410-433-2200

410-433-4615

Maryland Phys. Care MCO

509 Progress Drive

Linthicum, MD 21090-2256

800-953-8854

410-401-9532

410-609-1915

MedStar Family Choice

8094 Sandpiper Circle, Suite 0

Baltimore, MD 21236

(410) 933-3021

410-933-3002

410-933-2264

Priority Partners MCO

Baymeadow Industrial Park

6704 Curtis Court

Glen Burnie, MD 21060

(410) 424-4400

410-424-4960

410-424-4991

UnitedHealthcare

6095 Marshalee Dr., Suite 200

Elkridge, MD 21075

410-540-4312

410-540-5977

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PREGNANCY-RELATED SERVICES INITIATED PRIOR TO

MCO ENROLLMENT

Type of Provision: Continuity of Care

All pregnant women must have access to early prenatal care. When a HealthChoice

member suspects she is pregnant, she should contact her MCO/PCP. MCOs are responsible for

scheduling an initial prenatal or postpartum visit within 10 days of the enrollee’s request. If a

newly enrolled pregnant woman has already established care with an out-of-network provider

and that care included a full prenatal examination, risk assessment, and related laboratory tests,

then the provider may choose to continue providing prenatal care and the MCO must pay the

provider.

There are approximately 13,000 women a year who become eligible for Medicaid

because they are pregnant. When a low-income or uninsured woman seeks care for pregnancy

diagnosis and prenatal care, she should apply for the Maryland Children’s Health Program

(MCHP) at her local health department or call 1-800-456-8900 for information. Providers may

wish to keep a supply of the simple mail-in applications on hand to distribute to potentially

eligible women. The pregnant woman should send the completed MCHP application to the local

health department; the application will be processed within 10 days. After their eligibility for

Medicaid or MCHP is established most of these women will be required to enroll in

HealthChoice and must select an MCO. If they fail to select an MCO they will be auto-assigned.

OB Providers can assist in assuring continuity of prenatal care by following the steps

outlined below:

• Because early prenatal care is such a vital service, we encourage you to provide care

to pregnant women who are in the Medical Assistance application and MCO

selection process. You are not required to continue providing prenatal care to

pregnant women who subsequently enroll in an MCO in which you do not

participate. However, we encourage you to continue to see these women through

the self-referral option.

• If you participate in HealthChoice, let potential HealthChoice members know which

MCO(s) your practice participates in and whether you will accept women for out-of-

network prenatal care; and

• If you participate in one or more MCOs and have initiated prenatal care for a

pregnant woman who has Medical Assistance but is not in an MCO, encourage her

to select an MCO in which you participate. She should call the enrollment broker at

1-800-977-7388 to choose an MCO.

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In the event that an out-of-network provider has provided pre-enrollment care and initiated

prenatal care prior to the pregnant woman’s enrollment in an MCO, the prenatal care provider

may choose to continue rendering out-of-network prenatal care under these self-referral

provisions. The MCO is responsible for the payment of comprehensive prenatal care for a non

high-risk pregnancy, including prenatal, intrapartum and postpartum care at the established

Medicaid rate without preauthorization. The prenatal care provider should follow these

guidelines for the provision of self-referral pregnancy-related services:

• Inform the member’s MCO that you plan to continue to provide prenatal care to the

member as an out-of-network provider.

• Refer the member to the MCO’s OB case management services or special needs

coordinator (MCOs are required to have these services for pregnant women);

• Screen the member for substance abuse using a screening instrument which is used

for the detection of both alcohol and drug abuse, recommended by the Substance

Abuse and Mental Health Services Administration (SAMSA) of the U.S.

Department of Health and Human Services, and appropriate for the age of the

patient. Refer to the MCO’s Behavioral Health Organization, if indicated.

• Complete the Maryland Prenatal Risk Assessment Form (DHMH 4850) and forward

the form to the appropriate local health department’s Healthy Start Program. Prior

to the pregnant women’s enrollment in an MCO, completion of the risk assessment

is billed to MA using billing code H1000.

• Refer the member to the WIC Program at 1-800-242-4WIC.

• Providers should document in the medical record that health education and

counseling appropriate to the needs of the pregnant woman was provided. The

provider may then bill the MCO for an “Enriched” maternity service at each visit

using billing code H1003.

• When consultation or referral for high-risk prenatal care is indicated, make referrals

to the member’s MCO network providers only.

• Bill the member’s MCO for laboratory, radiology, and pharmacy services when they

are provided on-site in conjunction with the pregnancy-related services.

• When it is necessary to refer off-site for laboratory, radiology, and pharmacy

services, use only those providers who are in the member’s MCO network.

• Prior to the eighth month of pregnancy, the prenatal care provider should instruct the

pregnant woman to contact her MCO for assistance in choosing a primary care

provider for the newborn.

• For all non-pregnancy-related medical services, refer pregnant women to their

primary care provider (PCP).

19

Prenatal care providers typically bill MCOs by using CPT codes (99201-99205 and 99211-

99215) and two Healthy Start codes (H1000 AND H1003). The most commonly used codes are

listed below:


ON LINE AT:



99201 Office visit, new patient, minimal

99202 Office visit, new patient, moderate

99203 Office visit, new patient, extended

99204 Office visit, new patient, comprehensive

99205 Office visit, new patient, complicated

99211 Office visit, established patient, minimal

99212 Office visit, established patient, moderate

99213 Office visit, established patient, extended

99214 Office visit, established patient, comprehensive

99215 Office visit, established patient, complicated

H1000 Prenatal care at risk assessment

H1003 Prenatal care at risk assessment-Enhanced

Service

59410 Vaginal delivery including postpartum care

59515 Cesarean delivery including postpartum care

59430 Postpartum care

MCOs are responsible for payment of circumcisions performed by an obstetrician who

provided delivery services for a woman under the self-referral provision. When billing for

newborn circumcisions (CPT 54150 and 54160), you must use the newborn’s name and

Medical Assistance number. Contact the nurse consultant in the Division of Outreach and

Care Coordination at (410) 767-6750 for additional information.


20

RENAL DIALYSIS SERVICES PROVIDED IN A MEDICARE-

CERTIFIED FACILITY


HealthChoice members with end stage renal disease (ESRD) need access to renal dialysis

services provided in Medicare-certified facilities. Renal dialysis services substitute for the loss

of renal function for those individuals with chronic kidney disease. Renal dialysis services

include: chronic hemodialysis; chronic peritoneal dialysis; home dialysis and home dialysis

training; and laboratory testing and physician services which are not included in the composite

Medicare rate for dialysis.

Enrollment in REM or MCO:

• Most recipients diagnosed with ESRD are now enrolled in Rare and Expensive Case

Management Program (REM) except those who have elected to enroll or remain in

the MCO with the Program’s approval.

• Out-of-network providers must coordinate referrals to specialists and hospitals

through the MCO Utilization Management services.

For those renal dialysis patients remaining in HealthChoice, MCOs are responsible for

reimbursing for renal dialysis services in Medicare-certified facilities at the Medicaid rate.

Medicaid reimbursement is consistent with the rates paid by the Medicare program. The list of

codes for free-standing dialysis facilities are as follow:


ON LINE AT:



21

Maryland Medicaid Program Created Dialysis Facility Services Codes

Composite Rate Codes In

Medicare Revenue Code Original Description Medicaid Revenue Code

HEMODIALYSIS

821-71

Hemodialysis staff assisted

0821

821-72

Hemodialysis self care in unit

0821

821-76

Hemodialysis, back-up in facility

0821

821-73

Hemodialysis, self care training

0820

821-74

Hemodialysis, home care

0825

821-75

Hemodialysis, home care 100%

0829

PERITONEAL DIALYSIS

831-71 Peritoneal staff assisted

0831

831-72 Peritoneal self care in unit

0831

831-76 Peritoneal self care back-up in

facility

0831

831-73

Peritoneal self care training 0830

831-74 Peritoneal home care

0835

831-75 Peritoneal home care 100%

0839

CAPD (Continuous Ambulatory Peritoneal Dialysis)

841-71 CAPD, staff assisted

0841

841-72 CAPD, self care in unit

0841

841-76 CAPD, back-up in facility

0841

841-73 CAPD, self care training

0840

841-74 CAPD, home care

0841

841-75 CAPD, home care 100%

0849

CCPD (Continuous Cycling Peritoneal Dialysis)

851-71 CCPD, staff assisted

0851

851-72 CCPD, self care in unit

0851

851-76 CCPD, back-up in facility

0851

851-73 CCPD, self care training

0850

851-74 CCPD, home care

0851

851-75 CCPD, home care 100%

0859

When billing the MCO, the facility must attach a copy of the dialysis facility’s Medicare

Carrier Rate Letter to the initial UB04 claim form. Requests for MCO payment should be

submitted on the invoice and using the procedure codes specified by the MCO.

Contact the staff specialist for dialysis services at (410) 767-1426. For additional

information related to reimbursement of the physician services provided during a dialysis

session, please call (410) 767-1482.

22

SCHOOL BASED HEALTH CENTER SERVICES


SBHCs will establish relationships with the MCOs and their network primary care providers in

order to effectively utilize a co-management model of care to improve student-enrollees’ access

to quality health and mental health services. SBHC’s will be reimbursed by the student-

enrollees’ MCO under the self-referred provision for the following medically necessary primary

care services:

• Comprehensive well-child care when performed by Early and Periodic

Screening Diagnosis and Treatment (EPSDT) certified providers and rendered

according to Healthy Kids/EPSDT standards as described in the Healthy Kids

Manual published at:

http://www.dhmh.state.md.us/epsdt/healthykids/manual/table_contents.htm

• Follow-up of positive or suspect EPSDT screening components without approval of

the PCP except where referral for specialty care is indicated;

• Diagnosis and treatment of illness and injury that can be effectively managed in a

primary care setting;

• Family planning services as specified under the self-referred family planning section

of this manual.

Requirements

SBHCs must:

• Meet all the requirements established in COMAR 10.09.68- Maryland

Managed Care Program: School-Based Health Centers, and 10.09.08

Freestanding Clinics, and Early and Periodic Screening Diagnosis and

Treatment 10.09.23;

• Follow the guidelines and periodicity schedule established by the Maryland Healthy

Kids Program for well-child care and immunizations as published at:


• Utilize the American Academy of Pediatrics guidelines and other pertinent medical

guidelines to develop protocols and procedures for the management of common

illnesses, chronic disease and injuries, including the prescribing and management of

prescription drugs;

• Participate in the Vaccines For Children Program (VFC) and submit vaccination

information through the Maryland immunization registry, ImmuNet;



23

• Keep medical records in compliance with Medicaid and MCO standards and

procedures; and

• Participate in the Department’s quality assurance activities and allow MCOs and

the Department to conduct medical record reviews.

Communication with the MCO and PCP

• The MCO will continue to assign each student-enrollee a primary care provider.

The receipt of self-referred services in a SBHC shall be communicated to the PCP

and shall not impact the student-enrollee’s ability to access care from the PCP.

• The MCO and SBHC must establish a mutually agreeable communication protocol

which addresses care coordination and co-management protocols. At a minimum

communication will occur within three business days of service provision as

follows:

1. The SBHC will transmit a Health Visit Report to the MCO and the PCP for

inclusion in the recipient’s medical record. Information may be transmitted

by email, fax, or mail.

2. The SBHC will document communication details in student’s health center

medical record.

3. If follow-up care with the PCP is required within one week and the Health

Visit Report is mailed, the SBHC must also telephone, email or fax the

Health Visit Report to the PCP on the day of the SBHC visit.

4. When a Healthy Kids/EPSDT preventive care service is rendered, the SBHC

is required to use the age-appropriate preventive care form developed by the

Program. The completed form is to be sent to the PCP’s office for inclusion

in the enrollee’s medical record.

Limitations and Excluded Services

Services to non-students (e.g., school employees, students’ parents, or individuals from the

community) are not covered under these provisions.

MCOs will not reimburse SBHCs for services such as:

• Nursing services provided to enable a student to be safely maintained in the school

setting, such as: gastroesphogeal tube (GT) feedings; catheterization; oral nasal or

tracheal suctioning; and nebulizer treatments;

• Nursing or other health services provided as part of a student’s IEP/IFSP;

• School health services which are required in all school settings, such as: routine

assessment of minor injuries; first aid; administration of medications, including the

supervision of self-administered medications; general health promotion counseling;

and review of health records to determine compliance with school mandates, such

as immunization and lead requirements;

24

• Mandated health screening services performed at specific intervals in all public

schools such as hearing, vision, and scoliosis screening;

• Routine sports physicals;

• Vaccines supplied by VFC;

• Visits for the sole purpose of: administering vaccines; administering medication;

checking blood pressure; measuring weight; interpreting lab results; or group or

individual health education;

• Services provided outside of the physical location of the approved SBHC;

• Services not covered by MCOs such as dental services and specialty mental health

services; and

• Services provided without prior authorization when prior authorization is required

by the MCO.

All reimbursement limitations described in COMAR 10.09.08.07- Freestanding Clinics and

COMAR 10.09.68.03B- Maryland Medicaid Managed Care Program: School- Based Health

Centers apply.

MCO and School-Based Health Center Policies and Procedures

Clear communication between the MCO, the PCP and the SBHC will ensure that

medically necessary care and treatment are given to recipients utilizing self-referred services.

The MCO is required to provide the following information to SBHCs in their service area:

• The contact information (name, phone number, e-mail, and fax numbers) of:

o The Special Needs/Care Coordinator and other relevant contacts needed to

facilitate co-management of student-enrollees;

o The MCO billing representative and the address for submitting paper claims

to the MCO; and

• Information on how to identify and contact the student-enrollee’s PCP.

• Policies and procedures regarding the MCO’s pharmacy coverage and formulary;

• Policies and procedures for the MCO’s contracted laboratory services with

LabCorp; and

The SBHC is required to adhere to the following:

25

• When the SBHC is unable to render or chooses not to render the pharmacy or

laboratory service in the SBHC, the SBHC must use the MCO’s formulary and in-

network pharmacy and contracted laboratory services with Lab Corp; and

• SBHCs must follow all MCO preauthorization requirements.

Billing Requirements

The SBHC must:

• Assure that no claims are submitted for services that the SBHC provides free of

charge to students without Medicaid coverage;

• Verify eligibility and MCO assignment through EVS on the day of service;

• If the client has other third party insurance, SBHCs must bill third party insurers

before billing the MCO, with the exception of well-child care and immunizations;

• Submit claims using the CMS-1500 or an EDI and HIPAA compliant electronic

submission according to the SBHC Instructions Manual provided by the

Department;

• Use place of service code “03” – School – on all claims;

• Submit claims within 180 days of performing a self-referred service;

For complete billing instructions consult the Billing Instructions for School-Based Health

Centers and Billing Instructions for Healthy Kids/EPSDT Providers.

Payment

• MCOs will reimburse SBHCs at the rates specified in the Maryland Medicaid

physician fee schedule, with the exception of FQHCs; and

• MCO’s will reimburse CPT code 99070, special contraceptive supplies, at cost.

For current fee schedule, consult the Medicaid Provider Fee Manaual at:


For a list of SBHCs, county locations and sponsors, or for additional information, contact (410)

767-1490.


26

SUBSTANCE ABUSE


Effective January 1, 2010, The Substance Abuse Improvement Initiative (SAII) allows

Medicaid enrollees to select their own provider for substance abuse treatment even if the

provider does not have a contract with a Managed Care Organization (MCO). The initiative uses

the American Society of Addiction Medicine’s (ASAM) Patient Placement Criteria – a widely

used and comprehensive national guideline for placement, continued stay, and discharge of

patients with alcohol and other drug problems – to evaluate level of care (LOC).

This section provides a narrative description of the revisions to the notification and authorization

requirements for self-referred services under HealthChoice. Self-referral protocols are listed by

ASAM level. It is important to note that these protocols do not lay out any benefit limitations.

Rather, services beyond these must be justified based on medical necessity according to ASAM.

Comprehensive Substance Abuse Assessment

Under the self-referral initiative, an MCO or the Behavioral Health Organization (BHO) which

administers the substance abuse services for certain MCOs will cover a Comprehensive

Substance Abuse Assessment once per enrollee per provider per 12-month period, unless there is

more than a 30-day break in treatment. If a patient returns to treatment after 30 days, the

MCO/BHO will pay for another CSAA. This is a new feature of the initiative which begins on

January 1, 2009.

ASAM Level I.D – Ambulatory Detox

In regards to the self-referral option under HealthChoice, ambulatory detox refers to detox

services provided in the community or in outpatient departments of hospitals or outpatient

programs of intermediate care facilities-alcohol (ICF-A).

Provider Communication Responsibility

Provider must notify MCO/BHO and provide treatment plan (by fax or email)

within one (1) business day of admission to ambulatory detox.

MCO/BHO Communication Responsibility

The MCO/BHO will respond to provider within one (1) business day of receipt

with final disposition concerning ASAM criteria, including confirmation/

authorization number if approved.

Approval Protocol

1) If MCO/BHO does not respond to provider’s notification, MCO/BHO will pay

up to five (5) days.

27

2) If MCO/BHO responds by approving authorization, a LOS of five (5) days will

automatically be approved. Additional days must be preauthorized as meeting

medical necessity criteria.

3) If MCO/BHO determines client does not meet ASAM LOC, the MCO/BHO

will pay for care up to the point where they formally communicate their

disapproval.

ASAM Level: I – Outpatient Services - Individual, family and group therapy

Self-referred individual or group therapy services must be provided in the community (not in

hospital rate regulated settings).1 Hospital-based providers must seek preauthorization to be

reimbursed for these services from an MCO/BHO.


Provider must notify (by fax or email) the MCO/BHO and provide initial

treatment plan within three (3) business days of admission to Level I therapy

services.


The MCO/BHO must respond to provider within two (2) business days of receipt

with confirmation of receipt of notification.

Approval Protocol

The MCO/BHO will pay for 30 sessions (any combination of individual, group,

and family therapy) within 12-month period per client (family sessions are billed

under the individual enrollee’s number). The 30 visits are not a benefit limitation.

Rather, the provider must seek preauthorization for additional individual or group

therapy services during the year. Medicaid MCOs will pay for additional

individual and group counseling services as long as medically necessary.

In order for a provider to bill for family counseling, the enrollee must be present

for an appropriate length of time but does not need to be present for the entire

counseling session. In some circumstances the counselor might spend part of the

session with the family out of the presence of the enrollee.

ASAM Level: II.1 – Intensive Outpatient (IOP)

1 Hospital rate regulated clinics must seek preauthorization to provide such services under HealthChoice.

28

Self-referred intensive outpatient only applies to care delivered in community-based settings.

Providers must seek preauthorization to provide such services. In preauthorizing, MCOs may

refer to in-network community providers if those providers are easily available geographically

and with out waiting lists.


The Provider must notify and provide treatment plan to MCO/BHO (by fax or

email) within three (3) business days of admission to IOP. If they do not notify,

they will not be paid for services rendered.


The MCO/BHO will respond to provider (by fax or email) within two (2) business

days with final disposition concerning ASAM criteria, including confirmation

number if approved.

Approval Protocol

If the treatment plan is approved, MCO will pay for 30 calendar days. At the end

of week three (3), for care coordination purposes, the provider must notify the

MCO/BHO of discharge plan or need for remaining treatment. Continuing

treatment beyond the 30 days must be preauthorized as being medically

necessary.

If determined that client does not meet ASAM LOC, MCO/BHO will pay for all

services delivered up until the point that they formally notify the provider of the

denial. If the client does not qualify for IOP, the MCO/BHO will work with the

provider to determine the appropriate level of care.

ASAM Level: II.5 – Partial Hospitalization

This service is provided in a hospital or other facility setting.


By morning of second day of admission to this service setting, provider will

review client’s Treatment Plan with MCO/BHO by telephone. Provider must

submit progress report and assessment for justification of continued stay beyond

day five (5). Provider obtains patient consent and submits progress report or

discharge summary to PCP for their records and coordination of care within 10

days.


MCO/BHO will respond to providers within two (2) hours of review.

Confirmation number will be provided. MCO/BHO must have 24/7 availability

for case discussion with provider.

29

Approval Protocol

1) Two (2) day minimum guaranteed. If ASAM is met, MCO/BHO will authorize

an additional three (3) days. Any additional days must be preauthorized by the

MCO/BHO based on medical necessity.

2) If the MCO/BHO is not available or does not respond to provider within two

(2) hours, they will pay the extra three (3) days. Any additional days must be

preauthorized by the MCO/BHO based on medical necessity.

Providers shall seek the least restrictive level of care for clients. If the client does

not qualify for partial hospitalization, the MCO/BHO will work with the provider

to determine the appropriate level of care.

ASAM Level: III – Residential and Inpatient – ICF-A, under 21 years

ICF-A services are only available for children and adolescents under age 21 for as long as

medically necessary and the enrollee is eligible for the service. Medicaid does not pay for

services if they are not medically necessary, even if a Court has ordered them. HealthChoice

MCOs do not cover other residential services.


Within two (2) hours, provider calls MCO/BHO for authorization.


MCO/BHO will respond to provider within two (2) hours with a final disposition

concerning ASAM criteria, including confirmation number if approved.

MCO/BHO must have 24/7 availability.

Approval Protocol

1) If MCO/BHO does not respond to urgent call, up to three (3) days will be paid.

Additional days must be preauthorized.

2) If ASAM is met and MCO/BHO has authorized, a LOS of three (3) days will

be approved. Additional days must be preauthorized.

3) If client does not meet criteria, the MCO/BHO will work with provider to

determine appropriate level of care.

ASAM Level: Opioid Maintenance Treatment - Methadone

In regard to the self-referral option, methadone maintenance refers to services provided in the

community or outpatient departments of hospitals.

30


Within five (5) calendar days of admission to methadone program, provider

notifies MCO/BHO (by fax or email) and submits initial treatment plan.

After obtaining the patient’s consent, the provider will also inform the patient’s

Primary Care Provider that patient is in treatment.

The provider will submit an updated treatment plan to the MCO/BHO at the 12th

week of service to promote the coordination of care. Next approvals for

continued care will be at six-month intervals.


MCO/BHO will respond to provider within two (2) business days (by fax or

email) with final disposition, including confirmation number if approved. They

will also assist provider with contact information concerning the patient’s PCP.

Approval Protocol

If approved, MCO/BHO will pay for 26 weeks under the self-referral option.

Medicaid coverage is determined by medical necessity. Unit of service is one

week. Any care provided prior to a denial based on medical necessity will be paid

by the MCO/BHO. Additional approvals for continued care beyond the first 26

weeks will be at six-month intervals.

ASAM Level: IV.D: Medically Managed Patient – Inpatient Detox in an Inpatient Hospital

Setting or in an ICF-A Facility

This service is provided in a hospital or ICF-A setting.


Within two (2) hours, provider calls MCO/BHO for authorization.


MCO/BHO will respond to provider within two (2) hours with a final

authorization or disposition, including confirmation number if approved.

MCO/BHO must have 24/7 availability.

Approval Protocol

1) If ASAM is met and MCO/BHO authorizes, a LOS of three (3) days will be

approved. Additional days must be preauthorized based on medical necessity.

31

2) If client does not meet criteria, the MCO/BHO will work with provider to


3) If MCO/BHO does not respond to the provider’s authorization call, up to three

(3) days will be paid. Additional days must be preauthorized based on medical

necessity.

MCO/BHO Authorization/Notification Numbers

For Substance Abuse Treatment Services

Managed Care Organization Behavioral Health

Organization

(BHO)

Number to call for Authorization/

Notification

(For both in- and out- of-network

providers)

AMERIGROUP Providers call

1-800-454-3730 Prompt 9

Members call

1-800-600-4441 Prompt 9

Fax 1-800 505-1193

DIAMOND PLAN

Coventry Health Care MHNet Behavioral

Health

1-800-454-0740

Fax: 407-831-0211

MEDSTAR Value Options 1-800-496-5849

JAI MEDICAL SYSTEMS

410-327-5100

Fax: 410-327-0542

MD PHYSICIANS CARE

1-800-953-8854

Option 7

Fax: 860-907-2649

PRIORITY PARTNERS 1-800-261-2429 Option 3

Fax: 410-424-4891

UNITEDHEALTH CARE United Behavioral

Health

1-888-291-2507

Fax: 1-800-248-8994

Providers: There is a period when an individual becomes eligible for Medicaid but is not

yet enrolled in an MCO. Check the Eligibility Verification System (EVS) to determine the

person’s status. For information about the EVS, call (410) 767-5503.

32

HealthChoice Substance Abuse Treatment Self-Referral Protocols – in ASAM Order Substance Abuse Improvement Initiative (SAII)

January 1, 2010

Billing Codes: Sub Abuse TX & Procedure Codes

Provider Communication

Responsibility

MCO/BHO Communication

Responsibility

Approval Criteria

H0001

NA

NA

1) A Managed Care Organization (MCO) or

the Behavioral Health Organization (BHO)

which administers the substance abuse

services for certain MCOs will pay for a

Comprehensive Substance Abuse

Assessment once per enrollee per provider

per 12-month period, unless there is more

than a 30-day break in treatment. If a

patient returns to treatment after 30 days, the

MCO/BHO will pay for another CSAA.

H0014 for

Provider must notify

MCO or BHO liaison will

1) If MCO/BHO does not respond to community-based MCO/BHO and provide respond to provider within provider’s notification, MCO/BHO will pay up

providers using treatment plan (by fax or one (1) business day of to five (5) days.

CMS 1500 email) within one (1) business receipt with final disposition day of admission to ambulatory concerning ASAM criteria, 2) If MCO/BHO responds by approving

detox. including confirmation authorization, a LOS of five (5) days will

0944 and 0945 number if approved. automatically be approved. Additional days

revenue codes for must be preauthorized as meeting medical

33



Responsibility


Responsibility

Approval Criteria

facility-based

providers using

UB-04

necessity criteria.

3) If MCO/BHO determines client does not

meet ASAM LOC, MCO/BHO will pay for

care up to the point where they formally

communicate their disapproval.

H0004 for

individual or

family therapy

H0005 for group

therapy

Provider must notify (by fax or

email) MCO/BHO and provide

initial treatment plan within

three (3) business days of

admission to Level I therapy

services

MCO or BHO liaison must

respond to provider within

two (2) business days of

receipt with confirmation of

receipt of notification.

MCO/BHO will pay for 30 self-referred

sessions (any combination of individual, group,

and family therapy) within 12-month period

per client.

Any other individual or group therapy services

within the 12-month period must be

preauthorized. Medicaid MCOs/BHOs will

pay for additional counseling services as long

as deemed medically necessary.

In order for a provider to bill for family

counseling, the enrollee must be present

for an appropriate length of time, but does not

need to be present for the entire counseling

session. In some circumstances the counselor

might spend part of the session with the family

out of the presence of the enrollee. Family

therapy is billed under the individual enrollee’s

Medicaid number.

34



Responsibility


Responsibility

Approval Criteria

H0015 for

Provider must notify and


If the treatment plan is approved, MCO/BHO

will pay for 30 calendar days of IOP. At the

end of week three (3), for care coordination

purposes, the provider must notify the MCO

of discharge plan or need for remaining

treatment. Continuing treatment beyond the

30 days must be preauthorized as being

medically necessary.

If determined that client does not meet ASAM

LOC, MCO/BHO will pay for all services

delivered up until the point that they formally

notify the provider of the denial. If the client

does not qualify for IOP, the MCO/BHO will

work with the provider to determine the

appropriate level of care.

community-based provide treatment plan to MCO respond to provider (by fax

providers using (by fax or email) within three or email) within two (2)

CMS 1500 (3) business days of admission business days with final

to IOP. If they do not notify, disposition concerning

they will not be paid for ASAM criteria, including

0906 revenue services rendered. confirmation number if

codes for facility- approved.

based providers using UB-04

0912 and 0913

By morning of second day of


1) Two (2) day minimum guaranteed. If revenue codes for admission to this service respond to providers within ASAM is met, MCO/BHO will authorize an

facility-based setting, provider will review two (2) hours of review. additional three (3) days. Any additional days

providers using client’s Treatment Plan with Confirmation number will be must be preauthorized by the MCO based on

UB-04 MCO/BHO by telephone. provided. medical necessity.

Provider must submit progress MCO/BHO must have 24/7 2) If the MCO/BHO is not available or does

report and assessment for availability for case not respond to provider within two (2) hours,

justification of continued stay discussion with provider. they will pay the extra three (3) days. Any

beyond day five (5). additional days must be preauthorized by the

MCO/BHO based on medical necessity.

Provider obtains patient consent and submits progress

35



Responsibility


Responsibility

Approval Criteria

report or discharge summary to

PCP for their records and

coordination of care within 10

days.

Providers shall provide the least restrictive

level of care. If the client does not qualify for

partial hospitalization, the MCO/BHO will

work with the provider to determine the


Providers should

Within two (2) hours, provider

MCO/BHO liaison will

1) If MCO does not respond to urgent call, up speak to calls MCO or BHO for respond to provider within to three (3) days will be paid. Additional days

MCOs/BHOs authorization. two (2) hours with a final must be preauthorized.

about appropriate disposition concerning codes to use ASAM criteria, including 2) If ASAM is met and MCO/BHO has

within their confirmation number if authorized, a LOS of three (3) days will be

billing systems approved. approved. Additional days must be

preauthorized.

MCO/BHO must have 24/7 availability. 3) If client does not meet criteria, the

MCO/BHO will work with provider to


36



Responsibility


Responsibility

Approval Criteria

H0020

Within five (5) calendar days

of admission to methadone

program, provider notifies

MCO/BHO (by fax or email)

and submits initial treatment

plan.

The provider will submit an

updated treatment plan to the

MCO/BHO by the 12th week

of service to promote the

coordination of care.

Next approvals will be at six-

month intervals.

MCO or BHO will respond

to provider within two (2)

business days (by fax or

email) with final disposition,

including confirmation/

authorization number if

approved.

The provider will inform the

PCP that patient is in

treatment after obtaining the

patient’s consent.

If approved, MCO/BHO will pay for 26 weeks

under the self-referral option.

Continued eligibility for coverage will be

determined by medical necessity.

Additional approvals beyond the first 26 weeks

will be at six-month intervals.

Unit of service is one week. Any care

provided prior to a denial based on medical

necessity will be paid by the MCO/BHO.

0126 and 0136

revenue codes for

facility-based

providers

Within two (2) hours, provider

calls MCO/BHO for

authorization.

MCO or BHO will respond

to provider within two (2)

hours with a final

disposition, including

confirmation number if

approved.

MCO/BHO must have 24/7

availability.

If ASAM is met and MCO/BHO authorizes, a

LOS of three (3) days will be approved.

Additional days must be preauthorized as

medically necessary.

If client does not meet criteria, the MCO/BHO

will work with provider to determine


If MCO/BHO does not respond to the

37



Responsibility


Responsibility

Approval Criteria

provider’s authorization call, up to three (3)

days will be paid. Additional days must be

preauthorized as medically necessary.

Footnotes

1. MCOs/BHOs must have 24/7 availability for Partial Hospitalization, ICF-A, and Inpatient Acute.

2. MCOs/BHOs will honor substance abuse authorizations for all services made by an enrollee’s previous MCO provided the ASAM

level of care continues to be met and there is no break in service. The provider must submit written verification of this authorization

to the new MCO within 72 hours of receiving it from the previous MCO.

3. MCOs pay the full FQHC per visit rate for services rendered.

4. An MCO/BHO may not require a peer-to-peer review for a pre-certification in cases where the patient is new and has not been seen

by the provider’s physician.

5. An MCO/BHO may not require written approval from a commercial insurer before deciding on a preauthorization in cases where the

patient has dual insurance.

6. Proof of notification is the faxed confirmation sheet and/or a documented phone conversation (date, time and person spoken to).

7. “One session” means a face-to-face meeting with a provider.

Note: HealthChoice regulations require the use of a placement appraisal to determine the appropriate level and intensity of care for

the enrollee based on the current edition of the American Society of Addiction Medicine Patient Placement Criteria, or its equivalent

as approved by the Alcohol and Drug Abuse Administration for most services covered under this protocol.

Department of Health and Mental Hygiene website: http://www.dhmh.state.md.us/

DHMH Provider Hotline: 1-800-766-8692

Or call the Complaint Resolution Unit’s supervisor, Ellen Mulcahy-Lehnert, or Division Chief, Ann Price, at

1-888-767-0013 or 1-410-767-6859 from 8:30 AM to 4:30 PM Monday - Friday

http://www.dhmh.state.md.us/

38

PLEASE PRINT Attach additional pages if more space is needed

Notification Treatment Plan

HealthChoice/DHMH

I. Please Circle One Initial Treatment Plan for:

Ambulatory Detox

Intensive Outpatient Treatment

X. Methadone Maintenance

Traditional Outpatient Treatment

Date contact made to MCO Name Date confirmation received MCO: from Time: am / pm Contact Name MCO:

Time: am / pm Please complete all sections. For confidentiality purposes, please do not write the client’s name in the body of the treatment plan. This information has been disclosed to you from records protected by Federal confidentiality rules (CFR 42 – part 2). The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by CFR 42- Part 2. A general authorization for the release of medical or other information is not sufficient for this purpose. The Federal rules restrict any use of this information to criminally investigate any alcohol or

drug abuse patient.

1.Client’s First Name Only 2. Client’s Date of Birth

/ / Mo Day Yr

3. Client’s Sex

M F

4a. Client’s MCO Number

4b.Client’s MA Number

5. Group Number* 6. Client’s Address & Phone Number

7. Clinician’s Name (Printed)

Clinician’s Signature Date

8. Clinic/Program Name, Address & Phone number

9. MA Provider Number 10. Referral Source 11. Primary Care Physician 12. Date of Last Exam

13a. Client Pregnant? Yes No 13b. If Yes, Due Date

14. OB/GYN: a. Pre Natal Appt Scheduled: b. Pre Natal Appt Completed: c. OB/GYN Knows of Pregnancy? Yes No

15. Date Present Treatment Began (mo, day, yr)

16. Diagnosis (Please complete all axes.) Use DSMIV Codes

AXIS I AXIS IV

AXIS II AXIS V (GAF)

AXIS III

17. Reason for Seeking Treatment/Motivation for Treatment

18. Substance Abuse History Toxicology Screen Drugs of Choice Last Use I Route Date Use Began I Frequency Date I Results Alcohol Barbiturates Cocaine Opioids Other

39



HealthChoice/DHMH

II. Please Circle One Initial Treatment Plan for:

Ambulatory Detox Intensive Outpatient Treatment

XI. Methadone Maintenance


19a. History of Delirium Tremens 19b. History of Blackouts 19c. Alcohol Related Seizures Yes Last date Yes Last Date Yes Last Date No No No

20. Substance Abuse Treatment History (Last 3 Years) 21. Medical Complications Allergies Heart Amputee Hepatitis Cirrhosis HIV Diabetes Hypertension Enlarged Liver Jaundice Gunshot Seizures Head Injury STDs Hearing Impaired Other

22. List All Medications (including Methadone/LAAM) Type Dosage Start Date Response

40



HealthChoice/DHMH

III. Please Circle One Initial Treatment Plan for:


XII. Methadone Maintenance


23. If medications are being administered by someone other than yourself, please identify.

24. Suicidal/Homicidal Behaviors? No Yes

Clarify If yes, is client able to contract for safety? List recent hospitalization or attempts

25. If client has a co-occurring psychiatric diagnosis, is client in treatment? Yes No 26. Client’s Mental Health Professional Phone

Number Release of Information Signed? Yes No

27. Psychosocial Functioning:

Domestic Violence

Drugs in the Home

Education Legal

Problems Primary Support

System Recovery

Environment

Working

Other

28. Brief Mental Status

41



HealthChoice/DHMH

IV. Please Circle One Initial Treatment Plan for:


XIII. Methadone Maintenance


29. Assessment Tools

MAST Score POSIT Score ASAM Criteria Dimensions: I II III IV V VI Level of Placement Assigned

30. Statement of Problem/s

Goals related to Presenting Problems (use finite / measurable / observable terms)** **12 STEP/Community Support/Spirituality

Short term: 1)

2)

3)

Long term: 1)

2)

3)

Client’s Signature Date 31. Type of Treatment Requested Frequency/Week Duration of EACH Session

IOP

Methadone Maintenance/LAAM Individual • 90804 (up to 30 min, non M.D.)

• 90806 (up to 60 min, non-M.D.) Group Other

42



HealthChoice/DHMH

V. Please Circle One Initial Treatment Plan for:


XIV. Methadone Maintenance


32. Anticipated Discharge Date: After Care Plan:

33. Comments (e.g. employment, family, housing, health status, socialization, support system)

For Ambulatory Detox Only

1. Vital Signs

BP Pulse Temperature Respiration Date taken Time taken am/pm

2. Withdrawal Symptoms

Agitation

Chills Piloerection (goosebumps)

Cramping Rhinorhea (runny nose)

Cravings Shakes

Diarrhea Sweating

Dilated pupils Tremors; Fine Gross

Lacrimation (runny eyes) Vomiting

Muscle aches Other

Nausea

43



HealthChoice/DHMH

VI. Please Circle One Initial Treatment Plan for:


XV. Methadone Maintenance


3. Medical Detox Protocol (Explain below or attach as a separate sheet)

44


Treatment Plan

HealthChoice/DHMH

Standard Information Required for Progress Report and Assessment of Continued Stay for

Partial Hospitalization


Time: am /

pm Please complete all sections. For confidentiality purposes, please do not write the client’s name in the body of the treatment plan.This

information has been disclosed to you from records protected by Federal confidentiality rules (CFR 42 – part 2). The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by CFR 42- Part 2. A general authorization for the release of medical or other information is not sufficient for this purpose. The Federal rules restrict any use of this information to criminally investigate any alcohol or

drug abuse patient.


/ / Mo Day Yr

3. Client’s Sex

M F


4b. Client’s MA Number







14. OB/GYN: d. Pre Natal Appt Scheduled: e. Pre Natal Appt Completed: f. OB/GYN Knows of Pregnancy? Yes No


16. Diagnosis (Please complete all axes. ) Use DSMIV Codes

AXIS I AXIS IV


AXIS III



45


Treatment Plan

HealthChoice/DHMH



19a. History of Delirium Tremens 19b. History of Blackouts

Seizures

Yes Last date Yes Last Date

Date

No No

19c. Alcohol Related

Yes Last

No

20. Substance Abuse Treatment History (Last 3 Years) 21.Medical Complications Allergies Heart Amputee Hepatitis Cirrhosis HIV Diabetes Hypertension Enlarged Liver Jaundice Gunshot Seizures Head Injury STDs Hearing Impaired Other

22. List All Medications (including Methadone)

Type Dosage

Start Date

Response

46


Treatment Plan

HealthChoice/DHMH




24. Suicidal/Homicidal Behaviors? No Yes Clarify

If yes, is client able to contract for safety? List recent hospitalization or attempts

25. If client has a co-occurring psychiatric diagnosis, is client in treatment? Yes No 26. Client’s Mental Health Professional Phone

Number Release of Information Signed? Yes No

27. Psychosocial Functioning:

Domestic Violence

Drugs in the Home

Education Legal

Problems Primary Support

System Recovery

Environment

Working

Other


47


Treatment Plan

HealthChoice/DHMH




MAST Score

POSIT Score

ASAM Criteria

Dimensions: I II III IV V VI

Level of Placement Assigned



Short term:

1)

2)

3)

Long term:

1)

2)

3)

Client’s Signature Date

48


Treatment Plan

HealthChoice/DHMH



Partial Hospitalization Per ASAM Level II.5 for Adults

Per ASAM Level II for Adolescents

For Scoring Purposes: Adults must meet one Dimension from Dimensions 4 or 5 or 6. Adolescents must meet one Dimension from Dimensions 3 or 4 or 5 or 6.

Justify specific behavioral and environmental conditions for level of care.

49

PLEASE PRINT Attach additional pages if more space is needed.

HealthChoice/DHMH Please Circle One

Standard Information Required for Telephonic Authorization for:

• Intermediate Care Facility Treatment

• Acute Inpatient Treatment


Time: am /

pm Please complete all sections. For confidentiality purposes, please do not write the client’s name in the body of the treatment plan.This information has been disclosed

to you from records protected by Federal confidentiality rules (CFR 42 – part 2). The Federal rules prohibit you from making any further disclosure of this

information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by CFR 42- Part 2. A

general authorization for the release of medical or other information is not sufficient for this purpose. The Federal rules restrict any use of this information to

criminally investigate any alcohol or drug abuse patient.


/ / Mo Day Yr

3. Client’s Sex

M F









14. OB/GYN: g. Pre Natal Appt Scheduled: h. Pre Natal Appt Completed: i. OB/GYN Knows of Pregnancy? Yes No



AXIS I AXIS IV


AXIS III



50






19a. History of Delirium Tremens 19b. History of Blackouts 19c. Alcohol Related Seizures

Yes Last date Yes Last Date Yes Last date

No No No

*20. Substance Abuse Treatment History (Last 3 Years) 21. Medical Complications Allergies

Heart

Amputee

Hepatitis

Cirrhosis

HIV

Diabetes

Hypertension

Enlarged Liver

Jaundice

Gunshot

Seizures

Head Injury

STDs

Hearing Impaired

Other

22. List All Medications (including Methadone/LAAM)

Type Dosage Start Date Response

51





• Acute Inpatient Treatment 23. If medications are being administered by someone other than yourself, please identify.

24. Suicidal/Homicidal Behaviors? No Yes Clarify If yes, is client able to contract for safety? List recent hospitalization or attempts

25. If client has a co-occurring psychiatric diagnosis, is client in treatment? Yes No

26. Client’s Mental Health Professional Phone Number

Release of Information Signed? Yes No

27. Psychosocial Functioning: Domestic Violence

Drugs in the Home

Education

Legal Problems

Primary Support System

Recovery Environment

Working

Other



MAST Score POSIT Score ASAM Criteria Dimensions: I II III IV V VI Level of Placement Assigned

52








Short term: 1)

2)

3)

Long term: 1)

2)

3)


53






Intermediate Care Facility Per ASAM Level III

For Scoring Purposes:

Client must meet two of six Dimensions.

For adolescents, client must meet the specifications in two of six Dimensions.

Justify specific behavioral and environmental conditions for ICF-A level of care.

54






Acute Inpatient Treatment Per ASAM Level IV

55

For Scoring Purposes:

Client must meet at least one Dimension from Dimensions 1 or 2 or 3 .

Justify specific behavioral and environmental conditions for level of care.

56


HealthChoice/DHMH Outpatient Concurrent Review

Authorization of Care Date contact made to MCO Name Date confirmation received MCO: from Time: am / pm Contact Name MCO:

Time: am /

pm

Please complete all sections. For confidentiality purposes, please do not write the client’s name in the body of the treatment plan.This information has been disclosed

to you from records protected by Federal confidentiality rules (CFR 42 – part 2). The Federal rules prohibit you from making any further disclosure of this

information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by CFR 42- Part 2. A

general authorization for the release of medical or other information is not sufficient for this purpose. The Federal rules restrict any use of this information to

criminally investigate any alcohol or drug abuse patient..

1.Client’s First Name Only 2. Client’s Date of Birth / / Mo Day Yr

3. Client’s Sex M F








13a. Date of Last Communication to Primary Care Physician

13b. Release Signed? Yes No

14. If Primary Care Physician not seen, indicate why:


16. OB/GYN: j. Pre Natal Appt Scheduled: k. Pre Natal Appt Completed: l. OB/GYN Knows of Pregnancy? Yes No



AXIS I AXIS IV


AXIS III

19. Response to Treatment (List specific gains made since initial treatment plan and all remaining symptoms with frequency and severity.)


57


HealthChoice/DHMH

Outpatient Concurrent Review Authorization of Care


23. Reasons for Continuing Treatment: (Including current ASAM Dimensions met)


Goals related to Presenting Problems (use finite / measurable / observable terms)** ** 12 STEP/Community Support/Spirituality

Short term: 1)

2)

3)

Long term:

1)

2)

3)


58


HealthChoice/DHMH


25. Urine Drug Screens/Breathalyzer Results Last 6 Tests

Positive Negative Dates Drug/Alcohol Screens Dates

26. Type of Treatment Requested Frequency/Week Duration of EACH Session IOP

Methadone Maintenance/LAAM Individual • 90804 (up to 30 min, non M.D.)

• 90806 (up to 60 min, non-M.D.) Group Other

27. Anticipated Discharge Date:

28. After Care Plan

29. Comments (e.g. employment, family, housing, health status, socialization, support system)

59


HealthChoice/DHMH


30. Methadone Maintenance/LAAM Only

A. Current Dosage

B.Discussed Therapeutic Detox with Client?

Yes Explain:

No Explain:

31.A. Is client currently using alcohol and/or illicit drugs? Yes No

B.List interventions to address usage (e.g. Administrative detox, change in level of care):

60

HealthChoice

Managed Care Organization

Resource List

AMERIGROUP Maryland, Inc.

7550 Teague Road. Ste 500

Hanover, MD 21076

Telephone Number: 410-859-5800 Fax Number: 410-981-4010

Utilization Review/Preauthorization: Telephone Number: 1-800-454-3730

Fax Number: 1-800-964-3627

Outreach/Case Management: Telephone Number: 1-800-454-3730

Fax Number: 1-800-964-3627

Member Services:

Telephone #: 1-800-600-4441

Fax #: 757-473-2736

Provider Services: Telephone #:: 1-800-454-3730

Fax #: 757-473-2736

Special Needs Coordinator: Telephone#: 410-981-4060

Fax#: 410-981-4065

Foster Care Liaison: Telephone#: 410-981-4060

Fax#: 410-981-4065

Diamond Plan Coventry Health Care of

Deleware, Inc.

Ambassador Center D

6310 Hillside Court

Suite 100

Columbia, MD 21046

Telephone Number: 443-436-3125 Fax Number: 443-436-3123

Utilization Review/Preauthorization: Telephone Number: 1-800-727-9951

Outreach: Telephone Number: 1-866-497-2475

Member Services: Telephone #: 1-866-533-5154 or

TDD: 1-877-843-1942

Provider Services Telephone #: 443-436-3111

Fax #: 1-866-212-5305 ext. 3111

Special Needs Coordinator: Telephone#: 1-800-727-9951 ext. 1730

Foster Care Liaison: Telephone#: 443-436-3159

61

Jai Medical Systems Inc.

5010 York Road

Baltimore, MD 21212

Telephone Number: 410-433-2200

Utilization Review/Preauthorization: Telephone #: 410-433-2200

Fax #: 410-433-8500

Outreach/Case Management:


Fax Number: 410-433-8500

Member Services:

Telephone#: 1-888-524-1999

Fax#: 410-433-4615

Provider Services:

Telephone #: 410-433-2200

Fax #: 410-433-4615

Special Needs Coordinator: Telephone#: 410-433-2200

Fax #: 410-433-8500

Foster Care Liaison:

Telephone#: 410-433-2200

Fax #: 410-433-4615

MedStar Family Choice

8094 Sandpiper Circle

Suite O

Baltimore, MD 21236


Fax Number: 410-933-3019

Preauthorization:

Telephone Number: 410-933-2200 or

1-800-905-1722 Option 1

Fax Number: 410-933-2274

Outreach/Case Management

Telephone Number: 410-933-2200 or

1-800-905-1722 Option 2

Fax Number: 410-933-2264

Member Services:

Telephone #: 1-888-404-3549

Provider Services:

Telephone #: 410-933-3069

Fax #: 410-933-3077

Special Needs Coordinator:

Telephone#: 410-933-2226

Fax #: 410-933-2209


Telephone#: 410-933-2226

Fax#: 410-933-2209

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Maryland Physicians Care

509 Progress Drive

Suite 117

Linthicum, MD 21090-2256


Utilization Review/Preauthorization:

Telephone Number: 1-800-953-8854 Option 2, Option 1

Fax Number: 1-800-953-8856

Outreach/Case Management

Telephone Number: 1-800-953-8854

Option 2

Fax Number: 410-609-1875

Member Services:

Telephone#: 1-800-953-8854, Option 1

Fax#: 410-401-9015

Provider Services:

Telephone #: 1-800-953-8854 Option 2

Fax #: 410-609-1927

Special Needs Coordinator

Telephone #: 410-401-9443

Fax #: 410-609-1875


Telephone#: 301-729-5642

Fax# 410-609-1849

Priority Partners

6704 Curtis Court Glen Burnie, Maryland 21060 Telephone Number: 410-424-4400

Fax: 410-424-4880 or 4883



1-800-261-2421 Fax Number: 410-424-4603

Outreach

Telephone Number: 410-424-4648 or 1-888-500-8786

Fax Number: 410-424-4884

Member Services:

Telephone #: 410-424-4500 or

1-800-654-9728 Fax #: 410-424-4895

Provider Services:

Telephone #r: 410-424-4490 or

1-888-819-1043

Fax #: 410-424-4895


Telephone#: 410-424-4906

Fax#: 410-424-4887


Telephone#: 410-424-4906

Fax#: 410-424-4887

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UnitedHealthcare

6095 Marshalee Drive

Elkridge, MD 21075


Fax Number: 410-379-3480


Telephone Number: 1-866-604-3267

Fax Number: 1-800-766-2917

Outreach:


Fax Number: 410-540-5990

Case Management:


Fax Number: 410-540-5977

Member Services:

Telephone #: 1-800-318-8821 Fax #: 410-379-3474

Provider Services:

Telephone #: 1-877-842-3210

Fax#: 410-379-3449


Telephone #: 410-540-4326

Fax #: 410-540-5977


Telephone#: 410-379-3460

Fax#: 410-540-5990

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